1. Tendinopathy: Current and Evolving Treatments
Kenzie Johnston, MD, CAQSM

2. Objectives Review the science of tendons
Discuss the confusing vocabulary surrounding tendinopathy
Touch on proposed pathology
Discuss escalating nonsurgical management and evidence (or lack there) for these interventions

3. Just a quick reminder
Tendons connect muscle to bone and allow transmission of forces generated by muscle to move bone
They save energy and improve power
(The patella tendon is actually a ligament)

5. Common tendinopathies
Rotator cuff tendinopathy
Lateral and medial epicondylitis
Patella tendinopathy
Achilles tendinopathy
Gluteal tendinopathy

6. How much does it matter?
Tendinopathy probably accounts for 30% of all running related injuries
40% of tennis players may have/had tennis elbow
Also affects people in the workforce - ex: mechanics with tennis elbow
Has anyone here never seen tennis elbow, jumpers knee, or Achilles tendinopathy

7. Some vocab
Tendons respond to repetitive overload beyond physiologic threshold with either inflammation of their sheath or degeneration of their body or both
Tendinopathy and Tenosynovitis
Tendinosis and Tendinitis are histologic terms and should not be used unless talking about histology

8. On a cellular level Basic cell biology of tendon is poorly understood
Oxygen consumption is 7.5 times lower than skeletal muscle allowing them to retain tension without risk of ischemia

9. Tendinopathy Extrinsic factors Biomechanics (ROM of the extremity)
Training type and training errors (surfaces, overload or underload)
Fluroquinolones…
Intrinsic factors
Age
Genetics
Extrinsic – load, surfaces, ROM of the extremity
Interesting, cipro and fluroquinolones induce cytokines and inflammatory PG, they also inhibit tenocyte metabolism

10. 3 big theories Mechanical Vascular Neuro
Tendon overload or nonuniform stress resulting in microtrauma or some cellular process (apoptosis, influx of cytokines, shift in proteolytic enzymes)
Underuse or underloading may also be bad
Hyperthermia (stored energy during locomotion)
Vascular
Poor blood supply and hypoxia resulting in tenocyte death
Oxidative stress from reperfusion (oxygen free radicals)
Neuro
Disruption of normal neural signaling resulting in abnormal cell metabolism, pain signaling, and blood flow

11. Healing
Done intrinsically (tenocytes) and extrinsically (invasion of cells from sheath and synovium)
Intrinsic is better as it results in better biomechanics
Extrinsic results in more scar tissue. This type of healing prevails in RTC

12. These are removed and normal collagen returns
Injury occurs
Acute factors migrate to site
24-48 hrs
These are replaced by proliferative factors: abnormal collagen, nerves, and blood vessels
6-12 weeks
These are removed and normal collagen returns

13. Histology of tendinopathy shows disordered haphazard healing with scattered vascular growth (neovascularization) and absence of or minimal inflammatory cells
Inflammation only seen with the most acute protocols (so maybe it kicks it off)
Macroscopically there is a color change and tendon thickening occurs
On ultrasound we see thickening, calcifications, small tears, neovascularization

14. Without inflammation why is there pain?
Increase in chemical irritants and neurotransmitters?
Lactate
Substance P
Glutamate

15. Diagnosis Clinical diagnosis Pain with palpation of affected tendon
Pain with tendon loading
No systemic causes
Less than 3 months we consider in acute phase and more than 3 months is considered chronic phase

16. Management
Subjectivity of signs and symptoms associated with tendinopathy makes research difficult
Little uniform in comparison intervention, duration of treatment, dosage or kit used in intervention, acuity of the condition, and measurement of efficacy

17. Bracing
Thought to change fulcrum of force or shutdown repetitive movements or perhaps enhance proprioception
Little evidence to support most of what we use (Elbow strap, patella strap, wrist brace, air heel, night splint or orthotic)
But overall low risk and usually low cost
Maybe if early enough can change or stop the process and allow tendon to make it through healing process?
Weak evidence showed that foot orthoses were equivalent to physical therapy, and equivalent to no treatment. Very weak evidence supported the use of adhesive taping alone or when combined with foot orthoses. Moderate evidence showed that the AirHeel™ brace was as effective as a calf muscle eccentric exercise programme, and weak evidence showed that this intervention was not beneficial when added to a calf muscle eccentric exercise programme. Weak evidence showed that an ankle joint dorsiflexion night splint was equally effective to a calf muscle eccentric exercise programme, and strong evidence showed that this intervention was not beneficial when added to a calf muscle eccentric exercise programme.
Counterforce bracing of lateral epicondylitis: a prospective randomized double blinded placebo clinical trial suggests that along with a exercise program a counterforce brace may be beneficial in terms of pain and function in the acute setting

18. NSAIDs Little evidence to no evidence
Possibly just analgesia and perhaps could interfere with healing process
Likely to be less effective in those with long standing pain

19. Exercise The most common intervention
Eccentric has been long prescribed (active lengthening) but we may be questioning
Strengthening program for rotator cuff
It may just be loading the tendon that is important
EE only produced good or excellent results in less than 60% of patients
Greatest evidence if with midsubstance lesions of the Achilles tendon (less so for insertional)
Some evidence for EE with patella tendinopathy and small evidence for lateral epicondylitis

20. Nitroglycerin Patches
May be of benefit
Well designed studies looking at Achilles, supraspinatus, and forearm extensors
Decreased pain with activities of daily living after 6 weeks
Perhaps nitrous oxide plays a role
Risk for headache (2/2 low BP)

21. My nitroglycerin directions
1. Use 0.2 mcg/24 hr patch 2. For the first week cut the patch into 1/8th and use that to reduce risk of headache 3. Place patch over painful area and change daily after shower 4. Increase to 1/4th a patch after one week, do not use more than 1/4th 5. Must use consistently for 6-8 weeks to start to notice a difference

22. Steroid injections Highly contentious and may put at risk of rupture
Effective for first 2-6 weeks but no long term benefit and perhaps less effective in long term than doing nothing or exercise (worse in pain and function for lateral epicondylitis)

23. When do I use steroid injections?
Rotator cuffs that have already tried several weeks of PT or are too painful to participate in PT
Once or twice for glute med/min with point tenderness
Only once for elbows if they have an upcoming event or competition
Only use with fat pad hydro dissection for patella (and only inject into fat pad)
Never for Achilles
Only if cannot tolerate PT for Plantar Fasciitis
No more than 3 in one spot is the unwritten rule
Did not show overall worse outcomes with SA injections

24. Fenestration Also known as partial tenotomy, dry needling
Theory: convert chronic into acute
PRP and Autologous blood often include this
Consider avoiding ASA and NSAIDs prior to and after procedure
Small studies have shown that this may improve pain and function for patients for various tendons, best studies have been with elbow, no good studies for the cuff
Billable and covered by insurance
Cuff no good studies – perhaps because these people tend to do well with surgery

25. Tenex device

26. Autologous Blood Platelets in blood would release growth factors
Early studies showed improvement in both pain and function but some recent studies comparing to steroid or saline have shown little difference
As effective as PRP at 6 mo in tennis elbow in 1 study
2011 Single blind randominized control trial

27. PRP Platelets release growth factors that aid in wound healing
Similar to autologous blood but more concentrated so perhaps better clinical response
Better than steroid but perhaps no better than saline
Great variance in type of PRP produced (leukocyte rich vs poor, concentration) and number of injections
Suggestions that leukocyte rich, high cell PRP with little anesthetic may be good for tendons
Metaanalysis of RCTs in PRP for various tendinopathies published in American Journal of Sports Medicine in 2016
Not covered by insurance (range anywhere 500 – 2000 a shot)

28. My proposed management algorithm
Pain less than 2-3 months?
Consider referral to sports med
Yes No
Modify activity
Consider brace
Start PT
Steroid injection for painful cuff or troch bursa
3-6 mo
> 6 mo and has failed PT
Modify activity PT
Steroid injection for painful cuff or troch bursa
Nitroglycerin for elbows, Achilles, patella
Consider fenestration vs Autologous Blood vs PRP for glutes, Achilles, elbow, PF, and patella and restart PT after a period of rest
For cuffs, consider PRP vs surgery
* Recommend confirmation of tendinopathy with MRI in all but elbow and PF

29. ESWT
Extracorporeal shock wave therapy may be useful in insertional and calcific tendinopathy but should only be considered if more traditional treatment as failed

30. Stem cells
May be promising in animal studies

31. We need better studies!
IMPROVE Study underway looking at PRP vs autologous blood vs fenestration vs PT Alone on Pain and Quality of Life in Tennis Elbow

32. Thank you! Kenzie.Johnston@duke.edu

33. References
Couppé, Christian, et al. “Eccentric or Concentric Exercises for the Treatment of Tendinopathies?” Journal of Orthopaedic & Sports Physical Therapy, vol. 45, no. 11, 2015, pp. 853–863., doi: /jospt
Fitzpatrick, Jane, et al. “The Effectiveness of Platelet-Rich Plasma in the Treatment of Tendinopathy: A Meta-Analysis of Randomized Controlled Clinical Trials.” The American Journal of Sports Medicine, vol. 45, no. 1, 2016, pp. 226–233., doi: /
Gambito, Ephraim D., et al. “Evidence on the Effectiveness of Topical Nitroglycerin in the Treatment of Tendinopathies: A Systematic Review and Meta-Analysis.” Archives of Physical Medicine and Rehabilitation, vol. 91, no. 8, 2010, pp. 1291–1305., doi: /j.apmr
Housner, Jeffrey A., et al. “Sonographically Guided Percutaneous Needle Tenotomy for the Treatment of Chronic Tendinosis.” Journal of Ultrasound in Medicine, vol. 28, no. 9, 2009, pp. 1187–1192., doi: /jum
Kesikburun, Serdar, et al. “Platelet-Rich Plasma Injections in the Treatment of Chronic Rotator Cuff Tendinopathy.” The American Journal of Sports Medicine, vol. 41, no. 11, 2013, pp. 2609–2616., doi: /
Rees, Jonathan D., et al. “Management of Tendinopathy.” The American Journal of Sports Medicine, vol. 37, no. 9, 2009, pp. 1855–1867., doi: /
Sharma, Pankaj, and Nicola Maffulli. “Tendon Injury and Tendinopathy.” The Journal of Bone & Joint Surgery, vol. 87, no. 1, 2005, pp. 187–202., doi: /jbjs.d
Vos, Robert J. De, et al. “Platelet-Rich Plasma Injection for Chronic Achilles Tendinopathy.” Jama, vol. 303, no. 2, 2010, p. 144., doi: /jama
Vos, Robert-Jan De, et al. “Strong Evidence against Platelet-Rich Plasma Injections for Chronic Lateral Epicondylar Tendinopathy: a Systematic Review.” British Journal of Sports Medicine, vol. 48, no. 12, 2014, pp. 952–956., doi: /bjsports